Reimbursement Policy Modifier JZ Requirement: Update - Vaccine and Monoclonal Antibody Products

Update December 20, 2024: Our policy states (Commercial Plan Policy Notification (PDF)) (Medicare Advantage Policy Notification (PDF)), Modifier JW or JZ is required when submitting claims for a single use vial or package of a drug or biological. In alignment with CMS guidelines, we do not require vaccines under section 1861(s) (10) (e.g. influenza, pneumococcal, COVID–19) to be reported with JW/JZ modifier. 

The following codes are considered monoclonal antibody products, not vaccine codes, and therefore require JZ or JW modifier reporting:

• 90380 – Respiratory syncytial virus (RSV), monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use,
• 90381 - Respiratory syncytial virus (RSV), monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use.

As noted, these products are not submitted as vaccine codes, and they are typically administered to children rather than adults. There are different codes for reporting the available RSV vaccines (currently recommended for adults ages 60 and up, as well as pregnant women).

Any claims denied due to lack of JZ modifier or a separate line with wastage (JW) must be resubmitted as a corrected claim per blue book instructions, incorporating the above JZ or JW modifier.

Effective November 1, 2024, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is implementing a revision to the reimbursement policy Drugs and Biologicals.

Consistent with CMS, Modifier JZ will now be required for a single-use vial or package when there is no discarded/wasted drug or biological. Modifier JW will continue to be required when there is discarded/wasted drugs or biologicals from a single use-vial or package.

In general, Modifier JW or JZ will be required on claims for single-use vial or package of drugs or biologicals. Failure to include Modifier JW or JZ will result in claim denial. Please see the related policy notification for more information.

This Modifier JZ requirement will ensure wastage is accurately coded on the claim – providing more insight and clarity into drug wastage and improving claim adjudication accuracy.

This change will apply to Commercial, Inter-Plan Program (IPP) Host, State Health Plan, Senior Market Administration (SMA), and Federal Employee Program (FEP). This will not apply to IPP Home.